Laparoscopy decreases complications for obese patients undergoing elective rectal surgery

The COMPARE Study: Comparing Perioperative Outcomes of Oncologic Minimally Invasive Laparoscopic, da Vinci Robotic, and Open Procedures: A Systematic Review and Meta-analysis of the Evidence

OBJECTIVE

To assess 30-day outcomes of da Vinci robotic-assisted (dV-RAS) versus laparoscopic or video-assisted thoracoscopic​​​​​ (lap/VATS) or open oncologic surgery.

BACKGROUND

Complex procedures in deep/narrow spaces especially benefit from dV-RAS. Prior procedure-specific comparisons are not generalizable.

METHODS

PubMed, Scopus, and EMBASE were systematically searched (latest: November 17, 2023) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and PROSPERO (Reg#CRD42023466759). Randomized, prospective, and database studies were pooled as odds ratios (ORs) or mean differences (MDs) in R using fixed effects or random effects (heterogeneity significant). ROBINS-I/RoB 2 were used to assess bias.

RESULTS

Of 56,314 unique references over 12 years from 22 countries, 230 studies (34 randomized, 74 prospective, and 122 database) comparing dV-RAS to lap/VATS or open surgery across 7 procedures, 4 specialties, representing 1,194,559 dV-RAS; 1,095,936 lap/VATS and 1,625,320 open cases were included. Operative time for dV-RAS was longer than lap/VATS [MD: 17.73 minutes (9.80, 25.67), P < 0.01] and open surgery [MD: 40.92 minutes (28.83, 53.00), P < 0.01], whereas hospital stay was shorter [lap/VATS MD: -0.51 days (-0.64, -0.38), P < 0.01; open MD: -1.85 days (-2.09, -1.62), P < 0.01] and blood loss was less versus open [MD: -293.44 mL (-359.53, -227.35)]. There were fewer dV-RAS conversions [OR: 0.44 (0.40, 0.49), P < 0.01], transfusions [OR: 0.79 (0.72, 0.88), P < 0.01], postoperative complications [OR: 0.90 (0.84, 0.96), P < 0.01], readmissions [OR: 0.91 (0.83, 0.99), P = 0.04], and deaths [OR: 0.86 (0.81, 0.92), P < 0.01] versus lap/VATS, and fewer transfusions [OR: 0.25 (0.21, 0.30), P < 0.01], postoperative complications [OR: 0.56 (0.52, 0.61), P < 0.01], readmissions [OR: 0.71 (0.63, 0.81), P < 0.01], operations [OR: 0.89 (0.81, 0.97), P < 0.01], and deaths [OR: 0.54 (0.47, 0.63), P < 0.01] versus open surgery. Blood loss [MD:- 12.26 mL (-29.44, 4.91), P = 0.16] and operations [OR: 1.03 (0.95, 1.11), P = 0.48] were similar for dV-RAS and lap/VATS. There was significant heterogeneity.

CONCLUSIONS

Da Vinci-RAS confers benefits across oncological procedures and study designs. These results provide clinical evidence to multispecialty-care decision-makers considering dV-RAS.

Evaluating body mass index's impact on Da Vinci Robotic rectal cancer surgery, a retrospective study

Robotic surgery addresses laparoscopic shortcomings and yields comparable results for low and high body mass index (BMI) patients. However, the impact of BMI on postoperative complications in robotic colorectal surgery remains debated. This study assessed the implications of BMI on short outcomes and postoperative complications, highlighting its unique role in the outcomes. Retrospective analysis of 119 patients who underwent robotic-assisted surgery for rectal cancer (January 2022 to March 2023). Patients grouped by BMI: normal weight (BMI < 23.9 kg/m2), overweight (BMI ≥ 23.9 kg/m2 and BMI < 27.9 kg/m2), and obese (BMI ≥ 27.9 kg/m2). Investigated BMI's impact on surgical outcomes and postoperative complications. Statistically significant differences (P < 0.05) in Clavien-Dindo, ASA scores. The obese group had a longer time to flatus (P = 0.002) and a higher re-operation rate than other groups (P = 0.01). The overweight group had a higher anastomotic fistula rate than the obese group. Overall complications showed no significant differences among BMI cohorts (P = 0.0295). There were no significant differences in TNM stages and comorbidities. BMI had no significant impact on overall postoperative complications in robotic surgery for rectal cancer. However, higher BMI correlated with a longer time to flatus and increased re-operation rate.

Laparoscopic versus open resection for stage II/III rectal cancer in obese patients: A multicenter propensity score-based analysis of short- and long-term outcomes

Aim

Whether a laparoscopic procedure can contribute to the improvement of clinical outcomes in obese patients with stage II/III rectal cancer compared to an open procedure remains unclear.

Objective

This study evaluated the technical and oncological safety of laparoscopic surgery versus open surgery in obese patients (body mass index [BMI] ≥25 kg/m2) with rectal cancer.

Patients and Methods

Data were collected from patients with pathological stage II/III rectal cancer and analyzed. Operations were performed via laparoscopic or open surgery from 2009 to 2013. A comparative analysis was performed after applying propensity score matching to the two cohorts (laparoscopic group and open group). The primary endpoint was 3-y relapse-free survival (RFS).

Results

Overall, 524 eligible cases were collected from 51 institutions. Equal numbers of propensity score-matched patients were included in the laparoscopic (n = 193) group and open (n = 193) group. Although the rate of D3 lymph node dissection did not differ between the laparoscopic group (87.0%) and the open group (88.6%), the median number of harvested lymph nodes was significantly lower in the laparoscopic group versus open group (17.5 vs 21, P = 0.0047). The median postoperative hospital stay was also significantly shorter in the laparoscopic group (14 d) vs the open group (17 d) (P = 0.0014). Three-y RFS was not significantly different between the two groups (hazard ratio 1.2454, 95% confidence interval 0.9201-1.6884, P = 0.4689).

Conclusion

The short- and long-term results of this large cohort study (UMIN ID: UMIN000033529) indicated that laparoscopic surgery in obese rectal cancer patients has advantageous short-term outcomes and no disadvantageous long-term outcomes.

Operative Difficulty, Morbidity and Mortality Are Unrelated to Obesity in Elective or Emergency Laparoscopic Cholecystectomy and Bile Duct Exploration

OBJECTIVES

The challenges posed by laparoscopic cholecystectomy (LC) in obese patients and the methods of overcoming them have been addressed by many studies. However, no objective tool of reporting operative difficulty was used to adjust the outcomes and compare studies. The aim of this study was to establish whether obesity adds to the difficulty of LC and laparoscopic common bile duct exploration (LCBDE) and affects their outcomes on a specialist biliary unit with a high emergency workload.

METHODS

A prospectively maintained database of 4699 LCs and LCBDEs performed over 19 years was analysed. Data of patients with body mass index (BMI) ≥ 35, defined as grossly obese, was extracted and compared to a control group.

RESULTS

A total of 683 patients (14.5%) had a mean BMI of 39.9 (35-63), of which 63.4% met the definition of morbidly obese. They had significantly more females and significantly higher ASA II classifications. They had equal proportions of emergency admissions, similar incidence of operative difficulty grades 4 or 5 and no open conversions and were less likely to undergo LCBDE than non-obese patients. There were no significant differences in median operative times, morbidity, readmission or mortality rates.

CONCLUSIONS

This study, the first to classify gall stone surgery in obese patients according to operative difficulty grading, showed no difference in complexity when compared to the non-obese. Refining access and closure techniques is key to avoiding difficulties. Index admission surgery for biliary emergencies prevents multiple admissions with potential complications and should not be denied due to obesity.

Obesity: is it an additional risk factor in analyzing surgical outcomes in the South Indian population?

Aim

This study aims to determine whether obesity impacts surgical outcomes among patients undergoing surgery at the Surgery Unit in a tertiary care hospital.

Methods

This is a retrospective study. Data were retrieved from the medical records of patients who underwent surgery at a tertiary care hospital. Patient demographics, co-morbidities, intraoperative and postoperative pain scores and complications, if occurring, were compiled for each patient. Patients were subdivided into four subsets based on their disease profile. Each subset was divided into two groups based on their body mass index (BMI). Preoperative BMI greater than or equal to 25 kg/m² was classified as obese.

Results

The study showed that there is a considerable increase in the duration of surgery in obese when compared to non-obese. 30 days readmission rate was higher among obese in all the subsets. We find that in the subset of non-infective conditions, post operative pain mean ranking score is greater among obese (128.8 vs 109.6).

Conclusions

In conclusion, the impact of obesity resulted in increased duration of surgery and post-operative pain. The association between obesity and surgical outcome shows the importance to further research to find a way to prevention of some of the complications of surgery that could occur in patients with high BMI.

Video-Laparoscopic versus Open Surgery in Obese Patients with Colorectal Cancer: A Propensity Score Matching Study

Simple Summary

Extended evidence on minimally invasive surgery in colorectal cancer (CRC) settings is needed, especially as applied to obese patients. We aimed to explore and compare postoperative outcomes between open and video-laparoscopic (VL) surgery in two groups of obese patients undergoing surgical resection for CRC. VL surgery was found to reduce postoperative recovery time and the severity of complications. This Italian experience provides a further contribution to the short-term prognostic quality of minimally invasive VL surgery in obese patients.

Abstract

Background: Minimally invasive surgery in obese patients is still challenging, so exploring one more item in this research field ranks among the main goals of this research. We aimed to compare short-term postoperative outcomes of open and video-laparoscopic (VL) approaches in CRC obese patients undergoing colorectal resection. Methods: We performed a retrospective analysis of a surgical database including 138 patients diagnosed with CRC, undergoing VL (n = 87, 63%) and open (n = 51, 37%) colorectal surgery. As a first step, propensity score matching was performed to balance the comparison between the two intervention groups (VL and open) in order to avoid selection bias. The matched sample (N = 98) was used to run further regression models in order to analyze the observed VL surgery advantages in terms of postoperative outcome, focusing on hospitalization and severity of postoperative complications, according to the Clavien–Dindo classification. Results: The study sample was predominantly male (N = 86, 62.3%), and VL was more frequent than open surgery (63% versus 37%). The two subgroup results obtained before and after the propensity score matching showed comparable findings for age, gender, BMI, and tumor staging. The specimen length and postoperative time before discharge were longer in open surgery (OS) patients; the number of harvested lymph nodes was higher than in VL patients as well (p < 0.01). Linear regression models applied separately on the outcomes of interest showed that VL-treated patients had a shorter hospital stay by almost two days and about one point less Clavien–Dindo severity than OS patients on average, given the same exposure to confounding variables. Tumor staging was not found to have a significant role in influencing the short-term outcomes investigated. Conclusion: Comparing open and VL surgery, improved postoperative outcomes were observed for VL surgery in obese patients after surgical resection for CRC. Both postoperative recovery time and Clavien–Dindo severity were better with VL surgery.

Hybrid minimally invasive/open approach versus total minimally invasive approach for rectal cancer resection: short- and long-term results

OBJECTIVES

To reduce the technical challenges of a totally minimally invasive approach (TMA) and to decrease the morbidity associated with open surgery, a hybrid minimally invasive/open approach (HMOA) has been introduced as a surgical technique for rectal cancer. The aim of this study was to compare postoperative results and long-term oncologic outcomes between hybrid minimally invasive/open approach and totally minimally invasive approach in patients who underwent rectal resection for cancer.

METHODS

All patients with rectal cancer undergoing a totally minimally invasive approach or hybrid minimally invasive/open approach proctectomy between 2012 and 2016 were analyzed. Preoperative and postoperative outcomes were collected from a prospectively maintained institutional database.

RESULTS

Among 283 patients, 138 (48.8%) underwent a hybrid minimally invasive/open approach and 145 (51.2%) a totally minimally invasive approach. Preoperative characteristics were similar between groups except for distance from the anal verge, which was lower in totally minimally invasive approach group (50.7% vs 29%; p = 0.0008). Length of stay (LOS) was significantly longer in the hybrid minimally invasive/open approach group (6.4 vs 4.3; p = < 0.0001). The median follow-up was 29.6 (14-40.6) months. Overall survival and disease-free survival were not significantly different between groups.

CONCLUSIONS

Compared with a hybrid minimally invasive/open approach, a totally minimally invasive approach has a shorter length of stay and may improve short-term outcomes in patients undergoing proctectomy for cancer.

Laparoscopic Mesorectal Excision in Obesity: Novel Insights and Technical Strategies

INTRODUCTION

Obesity is a burgeoning problem worldwide. Although beneficial in obese patients, conventional laparoscopic mesorectal excision for rectal cancer is technically challenging, with a higher conversion rate to open compared with nonobese patients. We describe novel strategies to circumvent these difficulties.

TECHNIQUE

The key steps are 1) lateral-to-medial colonic mobilization and left-sided mesorectal excision with the surgeon on the patient's right; 2) switching to the patient's left for right-sided mesorectal excision; 3) further rectal retraction with cotton tape and preperitoneal fat sling; and 4) caudal-to-cephalad mobilization of colon after distal transection, which facilitates extrapelvic mesenteric dissection and vessel ligation.

RESULTS

These techniques optimize gravity to negate the lack of exposure due to visceral obesity. Triangulation is improved by changing the surgeon's position during mesorectal dissection. This allows accurate identification of anatomical planes and avoids excessive pneumoperitoneum pressures and Trendelenburg tilt.

CONCLUSIONS

Adopting these strategies can facilitate laparoscopic mesorectal excision in the obese patient and may reduce conversion to open.

Trends and outcomes in laparoscopic versus open surgery for rectal cancer from 2005 to 2016 using the ACS-NSQIP database, a retrospective cohort study

BACKGROUND

There is controversy regarding the use of laparoscopy for rectal cancer, especially after the ACOSOG Z6051 Randomized Clinical Trial determined that laparoscopy failed to meet non-inferiority compared with open surgery. With these new recommendations, the current practices for the treatment of rectal cancer across the country are unknown.

METHODS

Using the ACS-NSQIP database from 2005 to 2016, resections for rectal cancer were studied. The proportion of laparoscopic versus open surgeries performed was determined by year, and 16 30-day outcomes were studied in each group. Multiple logistic regression was utilized to determine the association between laparoscopic and open technique as well as odds of outcome over time.

RESULTS

A total of 31,795 resections were performed, 12,371 (38.9%) laparoscopically. Laparoscopy increased yearly from 9.8% in 2005 to 52.8% in 2016. All 30-day outcomes tended to favor laparoscopy with the exception of operating room time.

CONCLUSIONS

These data suggest that laparoscopic surgery has been widely adopted for treating patients with rectal cancer, and the trend continues despite the ACOSOG Z6051 recommendations suggesting that laparoscopic resection may not be best technique for resection. Stronger recommendations are needed to change current trends if laparoscopic surgery is not the appropriate treatment method for rectal cancer.

Thoracic Surgery Considerations in Obese Patients

The obesity epidemic in the United States has increased greatly over the past several decades, and thoracic surgeons are likely to see obese patients routinely in their practices. Obesity has direct deleterious health effects such as metabolic disorder and cardiovascular disease, and is associated with many cancers. Obese patients who need thoracic surgery pose practical challenges to many of the routine elements in perioperative management. Preoperative assessment of obesity-related comorbid conditions and risk stratification for surgery, thorough intraoperative planning for anesthesia and surgery, and postoperative strategies to optimize pulmonary hygiene and mobility minimize the risk of adverse outcomes.

Is There Any Reason Not to Perform Standard Laparoscopic Total Mesorectal Excision?

The curative treatment of locally advanced rectal cancer is currently based on chemoradiotherapy and total mesorectal excision (TME). Laparoscopy has developed considerably because of obvious clinical benefits such as reduced pain and shorter hospital stay. Recently, several prospective randomized clinical trials with long-term follow-up have showed that laparoscopy is noninferior to laparotomy with the same oncologic outcomes in terms of survival and local control rate. However, laparoscopic TME remains a challenging procedure requiring a high level of expertise and a long learning curve to ensure an adequate and safe resection. The only relative contraindication of laparoscopic rectal surgery is T4 rectal cancer extended beyond the plane of TME. In this situation, it is reasonable to consider an open resection to avoid an uncomplete resection. In obese and elderly patients, laparoscopic TME also provides the same benefits as in nonobese and younger patients but may be more difficult to achieve. This review summarizes current knowledge on the place of laparoscopic TME in the treatment of rectal cancer.

Application of spontaneously closing cannula ileostomy in laparoscopic anterior resection of rectal cancer

An anastomotic leak (AL) is the most serious complication observed in laparoscopic anterior resection of rectal cancer (LARRC). In order to protect anastomosis from AL and avoid stoma reversal surgery in patients with ileostomy, spontaneously closing cannula ileostomy (SCCI) was used in LARRC and its safety and feasibility were assessed in the present study. To the best of our knowledge, this is the first time that SCCI has been used in such a case. A total of 41 patients who underwent LARRC with SCCI or ileostomy procedures between November 2013 and August 2014 were retrospectively analyzed. The patient demographics, clinical features and surgical data were evaluated using a Mann-Whitney U-test, Fisher's exact test or linear-by-linear association. Demographics, surgical data and the majority of clinical features of the two groups were consistently similar. In the SCCI group, the length of postoperative stay, total cost and stoma period were significantly improved compared with those in the ileostomy group. Additionally, the median protective period in the SCCI group was 22 days [interquartile range (IQR), 19-22 days], the median time to cannula removal was 23 days (IQR, 20-24 days) and the median time to cannula stoma closure was 12 days (IQR, 11-13 days). No SCCI-associated complications occurred. No significant differences in routine complications, including staple-line bleeding, anastomotic leak, anastomotic dehiscence, anastomotic stenosis and wound infection, were identified between the two groups. In LARRC, the SCCI procedure was demonstrated to be a safe and feasible diverting technique to protect anastomosis from AL. In contrast to ileostomy, the SCCI procedure obviated the requirement for stoma reversal surgery, which resulted in decreased lengths of postoperative hospital stay, hospitalization costs and stoma periods.